From the Guidelines
Bilateral thalamic infarcts require immediate management with standard acute stroke protocols, including intravenous thrombolysis if eligible, and long-term management with antiplatelet therapy, statins, and comprehensive rehabilitation to improve morbidity, mortality, and quality of life. The diagnosis of bilateral thalamic infarcts can be challenging, but imaging techniques such as noncontrast computed tomographic scan and magnetic resonance venogram can help identify the condition, as seen in Figure 13 and Figure 12 from the study by 1. Key aspects of management include:
- Immediate intravenous thrombolysis (tPA) if the patient presents within 4.5 hours of symptom onset and meets eligibility criteria
- Antiplatelet therapy, such as aspirin 81-325mg daily or clopidogrel 75mg daily, to prevent recurrence
- Statins, like atorvastatin 40-80mg daily, to control blood pressure and reduce the risk of further vascular events
- Comprehensive rehabilitation, including physical, occupational, and speech therapy, to improve functional outcomes and quality of life The prognosis of bilateral thalamic infarcts varies widely, and thorough investigation for underlying causes, such as cardioembolism, small vessel disease, or hypercoagulable states, is necessary to prevent recurrence and guide secondary prevention strategies, as discussed in the study by 1.
From the Research
Causes of Bilateral Thalamus Infarcts
- Bilateral thalamic infarctions are rare and usually caused by vascular occlusions 2
- The main cause of bilateral paramedian thalamic infarcts is the occlusion of the artery of Percheron (AP) due to cardioembolism 3
- Arteriosclerosis is the primary etiology of bilateral thalamic infarction, including conditions such as native vessel stenosis or arterial-to-arterial embolism 4
- Cardiogenic or paradoxical embolism can also lead to thrombosis of the perforator branches innervating the thalamus 4
Diagnosis and Treatment
- Clinical presentations may not adequately differentiate between the vascular etiologies alone, and imaging technologies such as CT angiography and MR angiography are useful for distinguishing between arterial and venous causes of bithalamic infarctions 2
- Bilateral thalamic venous infarctions can be treated with anticoagulation medication and with thrombolysis in more severe cases 2
- Bilateral thalamic arterial infarctions may be treated with thrombolysis 2
- High level of suspicion based on clinical and imaging findings is essential for early diagnosis of this rare condition 3
Clinical Presentation and Prognosis
- Bilateral thalamic infarcts may result in more severe and longer lasting symptoms, including transient or permanent behavioral, sensory and oculomotor disturbances 5
- Clinical presentation of bilateral paramedian thalamic infarction may include loss of consciousness, vertical gaze palsy, and cognitive symptoms 3, 6
- Total recovery after bilateral paramedian thalamic infarct is possible, but rare 6
- Patients with bilateral thalamic infarcts may persist with cognitive symptoms and gaze abnormalities 3